The Prevalence of Psychological Disorders among Children with Diabetes Aged 5-12 Years Old Referred to the Endocrinology Clinic of Mofid Hospital, Tehran, Iran in 2014-2015

Objective: As there were a few studies on the mental disorders resulting from diabetes in children, this study aimed at investigating the prevalence of psychological disorders among children. Materials & Methods: We enrolled 323 children with diabetes type 1 aged 5-12 yr old referring to Endocrinology Clinic of Mofid Hospital, Tehran, Iran in 2014-2015. In addition, 317 healthy children were considered as control group. The materials used for data analysis were information form and questionnaire CSI-4 filled out by their parents. The filled questionnaires were rated in that day and then analyzed and diagnosed by the Pediatric Psychiatrist in order to determine the type and intensity of psychological disorder. Results were analyzed using SPSS 20. T tests, Scheffe post hoc test and Pearson’s correlation test were used for analysis of data. The amounts were significantly different at P<0.05. Results: In terms of Neuro-Evolutionary disorders, Attention-deficit (ADD), hyperactivity (HD) and Attention-deficit hyperactivity disorders (ADHD) in children with diabetes were significantly higher than those in healthy children (P=0.001). Severe fundamental depressive disorders were higher in diabetic children (P=0.001). In terms of anxiety disorder, a specific phobia and panic was significantly higher in diabetic children (P=0.005). Regarding aggressive behaviors, diabetic children were more disobedient and stubborn than the others. Conclusion: The prevalence of psychological disorders among diabetic children was higher than that of the others. As psychological disorders will effect on the life quality of children, improvement of life quality of diabetic children and adolescents, on-time diagnosis and treatment of psychological disorders in these patients seems essential.

orphanage, kindergarten, school, hospital and their home, so during childhood, a period of disease means serious damage and the postponement can lead to a serious disorder to growth and evolution of children (6). Regarding the prevalence level of this disease and the needs, patients face with during specific stages of growth and adolescence, WHO declares that, children's needs must be prioritized and supporting the mental and physical health of children can be accounted as one of the best investments for social and economic development of countries and to this end, children's health must be fully regarded (7).
The inconvenience that a chronic disease such as diabetes imposes on the person is an issue, and is not recognized from the viewpoint of a physician or nurse. It depends on what the patient feels.
The effect of diabetes and its side effects on the life quality have been unknown so far and the studies done on psychological diseases related to diabetes are limited (3). Body and mind are two aspects of human, which effect on one another continually and they can determine one another's condition (8). Suffering from chronic diseases can effect on different dimensions of life, as Tylor mentions: suffering from chronic diseases effects on patients' interactions with physical and social environment they live and changes their relations with their peers (9). Physical illnesses can cause mental disorders chemically and physiologically.
Patients with chronic physical diseases will have mental disorders and problems (8).
Health definition by WHO is as follows: Health involves in all physical, mental and social aspects, Depression has a mutual relationship with diabetes called a risky factor for having diabetes (13).
Most of psychological issues result from problems imposed by diabetes like diet, activity limitation, invasive monitoring blood sugar, daily injection of insulin, chronic physical complications, being hospitalized in hospital and shortening life expectancy (14). A normal emotional response is placed at the beginning of depression, but depression will occur by progression of disease.
Defense mechanism of denial and minimization can result in refusing diagnosis and observing treatment. Mental disorders in diabetic patients are more common than the public, nevertheless, most of them remain undiagnosed (15,16).  (15,18,19).
Depressed diabetic patients do not follow food and medicine diet so much, they had poorer control of blood sugar, poorer physical and mental function, more physical complications and frequent reference to emergency and hospitalization and spend more on mental health (20). In addition, depression in diabetic patients is prevailed by 44% and the level of depression in diabetic patients who have this kind of disease more than 10 yr is more than the other groups (7). Diabetic patients who lacked emotional disorder had more self -esteem and less depression than the patients with emotional disorder (21). The mean of anxiety, depression, disruptive disorder and shyness in adolescents with diabetes was more than that of adolescents without diabetes and they had more troubles with their family (22). The Prevalence of Psychological Disorders among Children with Diabetes Aged 5-12 Years Old Referred...

Regarding that there have been a few studies
on the psychological disorders resulting from diabetes in children, this study was done aiming at investigating the mental disorders in children aged 5-12 yr old.

Materials & Methods
This study was done by case control practice, which investigated the relationship between diabetes, and the prevalence of psychological

Statistical Analysis
Results were analyzed using SPSS 20 (Chicago, IL, USA). Mean (SD) and (%) were used for quantitative and qualitative data, respectively.
In order to investigate the difference of mental disorders between the diabetic and normal children, t test was used. Scheffe post-hoc test was used to investigate the difference between groups. Pearson correlation was used to determine the relationship between variables. P < 0.05 shows significantly difference.

Results
Comparing the prevalence of psychological disorders in diabetic children and healthy children.  Table 1. Only the attention deficit between diabetic children    There was a significant relationship between mental disorders, social anxiety disorder (P<0.05) and time duration of disease in diabetic children.

Discussion
In this study, psychological disorders resulting from diabetes in children aged 5-12 yr old were investigated. Diabetes is ever increasing disease.
Regarding the fact that childhood is an important period of growth in terms of biological, mental and cognitive aspects and during childhood, a period of disease can be a real harm and a delay can cause a serious disorder in growth and evolution of child. Therefore, diagnosis of psychological disorders in diabetic children is an important issue.
As a whole, the results from this study suggest that there was a significant difference between the mean of scores in both groups (diabetic and nondiabetic children) in terms of mental disorders indexes based on CSI-4 questionnaire (P<0.05). In this regard, the mean of scores in diabetic children in terms of AD, ADHD, MDD, ODD, specified phobia and panic was higher than healthy children were. In a study, the level of psychological disorders in diabetic children was three times more than normal children was, and the most common psychological disorders were anxiety and depression (23 which is consistent with the results our study (27).
They believe that diabetes mellitus type 2 effects on frontal lobe and hippocampus and results in ADHD. In the present study, suffering from MDD in diabetic patients was higher and the previous studies done about this issue approve it (28,29).
The stress resulting from diabetes, poor control of hemoglobin AIC, BMI and negative life events effect on MDD occurrence (30). In the present study, specified phobia and panic in diabetic patients was higher. It was shown that the prevalence of anxiety disorders in patients with diabetes was three times more than the normal population (31).
Regarding that diabetes is a chronic and disabling disease, it will effect on all areas of life and as a result, psychological problems are prevalent in these patients but regarding that more prevalence of anxiety disorder (generalized anxiety disorder, separation anxiety and social anxiety disorder) and OCD in our study, we can point to ever increasing of prevalence of psychological disorders among children in Iran which is worrying and needs more investigations and research.

Limitations
The attitude and cooperation of parents in filling the questionnaire were affected by the socioeconomic level and education level of patients, which could effect on the reliability of results. Applying the self-report tools is problematic and the testes may not be honest enough to express their problems and answer the questionnaires. These conditions were not controllable for the researches.
In conclusion, the prevalence of ADHD considerable prevalence among this group, its importance is obvious.